TRIAGE TECHNIQUES

Cindy Pezza, PMAC

Urgent Non-Urgent Emergent It is so important to understand the

difference in these types of calls

Doctors should take the time to differentiate and train staff, but many do not.

Here we will give examples and explanations of many common scenarios

Heel Pain for the past few months- worsening for

about a week (pain scale at 6 out of 10)

Toenails are elongated (without pain) and patient is going on

vacation in two weeks

Diabetic patient with red, hot, swollen foot

Factory worker jumped out of the back of his truck this

morning and heard a “crack.” His heel is extremely painful since. Bruising is visible and

increasing.

Four year old girl referred by pediatrician for gait analysis.

Toes seem to go out when walking and she trips all the

time.

Newly diagnosed diabetic was referred by PCP for foot

check up, dry skin and brittle nails

Long term patient with increased callus build up- no

significant pain unless barefoot

Teenage boy with painful, draining, ingrown toenail –

just showed his mother today after it worsened to

the point of being unable to wear closed shoes

Recurrent ingrown (fourth time)

irritation and slight redness began at corner of right great

toenail this morning

Heel pain for the past 8 months. The pain increased slightly over time and now is so “annoying” that the patient wants to come

in today

Referred by PCP for possible ganglion cyst that has

recently become painful with pressure- PCP feels it

needs to be drained

Borderline diabetic patient famous for “I think I may

have an ingrown.” Usually right around the time of

leaving for a cruise/vacation or extended visit with family

Patient with self diagnosed “plantar wart” that has recently doubled

in size- very painful

Non- compliant patient previously treated for plantar wart, now has another and

wants it “cut out”

Patient not seen in 5 years, history of heel/arch pain,

thinks orthotics are starting to wear and causing discomfort

when running

Middle aged “Thursday night basketball player”

twisted his ankle last week and it is still

swollen and painful

Elderly woman complaining of ankle weakness. She has seen 3 other

DPMs and didn’t like the “quick fix” of putting her in a brace. “I’m not

wearing one of those things.”

Non- compliant diabetic that has “no-showed” for his last three appointments, calls to say that

the sore on his foot is now larger and draining more.

A neurologist in the same building as your office, calls to schedule an appointment for a

patient with severe neuropathy, balance issues and elongated

toenails

A long term patient calls after discovering and

“odd looking dark pigmentation” on the

bottom of her foot

Painful self diagnosed Neuroma (web md) is afraid

that if she doesn’t have surgery, she will never wear

heels again

Patient Evaluations That Allow Doctors to

Treat Effectively

Do Our Doctors Have ESP?

Just in case the answer is NO, we must find ways to prepare them for each patient in the most

proficient way possible.

Reason For Visit

For many patients, similar conditions present with similar (or identical) symptoms and can be evaluated accordingly.

Other times, a more creative approach must be taken to obtain the information we need without wasting the doctors time.

The Intake Form

On every practice’s intake form there is a section marked:

Reason for today’s visit,

How may we help you?

What brings you to the office?

It Takes all KindsThe answer to this question can be a small novel

or my favorite. . . . .

“Reason for today’s visit: MY FEET”

It is Our ResponsibilityTo find out the true reason for the visit

The most pressing issue(s) if there are multiple

The history of the problem

The previous methods of treatment

The severity of the problem

To weed out all of the completely unrelated “stuff” that patients tell us

Thorough, Efficient Evaluations

The best way to find out the facts, quickly and thoroughly is to know what to ask, how to

phrase it and ways to redirect patients who may be easily distracted or begin talking about

unrelated matters.

Most of the TimeIt is NOT the fault of the assistant for this lack of

communication.

It is usually the fault of the doctor, manager or trainer, who did not spend the time explaining why certain details are so important and how much easier it is to treat patients effectively if all the facts are clearly documented.

Example:

Follow up heel pain (2 weeks after cortisone injection)Assistant documents “Patient presents two weeks

after having a cortisone injection in his left heel. He states that he followed the stretching and icing instructions but does not feel any better.”

Doctor Enters the Treatment Room

Doctor questions the patient about his lack of improvement. He asks and the patient replies:

Did you feel any relief after the injection?

“Sure, for the first 5 days, but then the pain came back.”

Are you continuing to ice and stretch daily?

“No, I stopped after the first two days, was I suppose to continue?”

A BIG differenceAfter asking these two questions, the doctor was

able to change the subjective portion of the chart note to read: “Patient presents two weeks after receiving a

cortisone injection in his left heel. He states that he did feel relief for 5 days and then the pain returned. He also states that he followed the stretching and icing instructions for 2 days and then stopped.

The Doctor was UpsetHowever, this was not the fault of the assistant

She was new to the practice and only instructed to read the plan of the last chart note and ask “Are you feeling better since the injection and did you follow the stretching and icing instructions?

The doctor never explained how a more thorough evaluation would help him to further develop his treatment plan.

Let’s try Some and See. . . A Volunteer Please. .

Reason For Visit:

“My heels are killing me and I can’t stand it any

more!”

Possible Questions:Where is the pain? (point)

How long have you had it and is it getting worse?

What have you tried to get relief?

Have you had this before?

Was there an injury that you can recall?

Do you have bad pain in the morning?

Do you wear any type of shoe insert?

Reason for Visit:

“The back of my foot is painful when I wear shoes”

Possible Questions:Where is the pain?(point)

How long have you had the pain?

Is it getting worse?

Does it hurt when you are barefoot?

Can you recall an injury?

What type of exercise/activities do you do?

Do you wear any type of shoe insert?

Reason for Visit

“I feel like my sock is bunched under my toes, but it’s not. I

also feel a clicking between my middle two toes – it’s becoming

annoying”

Possible Questions:How long ago did this condition begin?

Have you ever felt anything like this before?

Do you wear high heels often?

What types of physical activities do you do?

Do you wear any type of insert?

What have you tried to relieve the problem?

Reason for Visit

“I hurt my ankle last week playing basketball and it is still

swollen and painful”

Possible Questions:How did you injure the ankle- did it twist, buckle,

etc.?

Did you ice after the injury

Did you try any type of ankle brace or support?

Do you have a history of ankle sprains?

Did you have any bruising after the injury?

Do you wear any type of shoe insert?

Reason for Visit

“I have a bump on the side of my big toe and I’m having a hard time finding cute shoes

that fit me.”

Possible QuestionsHow long has it been a problem?

Does anyone else in your family have this issue?

Do you have pain on a regular basis?

Do you wear any type of shoe insert?

Reason for Visit

“I am here to discuss bunion surgery with the doctor. I have suffered with pain for years and was referred by a friend who was very pleased with the

doctor and the outcome of her surgery.”

Possible QuestionsHave you tried conservative methods of

treatment in the past?- custom orthotics, gels, pads, wider shoes?

Do you have a time frame for surgery?

Do you have recent x-rays of the foot/feet?

Will you be needing disability paperwork completed?

Reason for follow up visit

Heel pain - 2 weeks after first cortisone injection (this should

be an easy one)

Possible QuestionsHow are you feeling since the injection?

Did you have relief for a few days, a week, longer?

Do you continue to ice and stretch on a daily basis as it recommends in your instruction sheet?

Have you discussed custom orthotics with the doctor?

Are you going to be casted today for custom orthotics?

Reason for follow up

Neuroma- 2 weeks after injection

Possible Questions

Has your condition improved, worsened or remain unchanged since your last visit?

Have you been wearing the type of shoe recommended by the doctor?

Are you considering having custom orthotics made?

Have you been resting and icing the area?

Reason for Follow up

Ingrown toenail- 2 weeks after procedure

Possible Questions

How is the toe feeling since your procedure?

Are you still having any redness, drainage or tenderness around the nail?

Have you followed the post op care instructions (soaking, using the recommended wound care product, etc.)?

Reason for Follow up

Orthotics were dispensed 2 weeks ago

Wait. . . Let’s dispense orthotics first . . .

Possible QuestionsHow are you adjusting to your new orthotics?

Did you follow the instructions and break them in slowly to avoid discomfort and fatigue?

Are you able to wear your orthotics in all of your shoes?

Have you considered a second pair (maybe down the line) to keep in your dress shoes/athletic shoes so that you always have a pair available?

MY FAVORITE

Reason for visit- “Feet”

Possible Questions

Could you be more specific about the problem you are having with your feet?

How long have you had this problem?

Have you experienced symptoms like this before?

Does anyone in your family have a similar issue?

No Matter what the Reason

Work closely with your doctors and keep lines of communication open when it comes to meeting their expectations.

Just like we don’t expect our doctors to have ESP, they can’t expect us to read their minds!

Impress Your DoctorsWith your knowledge

Your attention to detail

Your eagerness to learn more

Your interest in improving patient care

Your desire to increase office efficiency

Your willingness to work as a true member of the team

And as Time Goes By . . . You will become an even more valuable asset to

your doctors and your practice